073407162-4-12-2023-52-CC-MPRE-CQTQ4W-20230412115103

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073407162
Report Date: 04/12/2023
Date Signed: 04/12/2023 11:51:17 AM

Document Has Been Signed on 04/12/2023 11:51 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	SRIVASTAVA, SHALINI		FACILITY NUMBER:	073407162
ADMINISTRATOR:	SRIVASTAVA, SHALINI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(925) 556-9265
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94582
CAPACITY:	14	CENSUS: 12	DATE:	04/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:47 AM
MET WITH:	Shalini Srivastava		TIME COMPLETED:	11:47 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 4/12/2023 at 9:47am Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Shalini Srivastava for an Unannounced 1-Year Inspection. Present during the inspection was the Licensee, her assistant Sumi Pothen and twelve (12) preschool age children. Licensee’s second assistant Radharani Pinnani arrived at 11:00am. Licensee lives in the home with her husband, Amrish Srivastava. Licensee’s home was toured for a health and safety inspection. The facility operates from 8:30am – 6:00pm, Monday - Friday. ON LIMITS AREA: Entire Detached In-Law Unit at the front of the property and Backyard OFF LIMITS AREA: Entire Main Home and Garage ISOLATION AREA: Half Bathroom in In-Law Unit The facility is a single story in-law unit owned by the Licensee. The unit consists of two (2) rooms, one (1) full bathroom, one (1) half bathroom, a full kitchen and a stackable washer and dryer. The inside of the unit was observed to be neat, clean with ample age-appropriate materials for the children. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas. Licensee provides food for the children, but the children bring their own lunch. All food that is brought from the children’s home is properly labeled and stored. All napping equipment is clean and well maintained. Licensee stated that she does not transport children. There is one (1) dog that stays in the main house and there are no firearms in the home. There are two (2) fully charged 3A40BC fire extinguishers in both rooms. There is one (1) working smoke detector in one room, one (1) working smoke/carbon monoxide detector in the other room and one carbon monoxide detector in the half bathroom. The unit is equipped with two heat/air conditioners that are placed just under the ceiling in both rooms making them inaccessible to the children in care. The backyard is fully fenced, clean, well maintained with ample age-appropriate materials for the children. There fruit trees and a tall fountain that is kept empty and no danger to the children in care.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: SRIVASTAVA, SHALINI	FACILITY NUMBER: 073407162
	VISIT DATE: 04/12/2023

NARRATIVE

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Licensee is operating within their licensed capacity and is in ratio. Licensee’s Health and Safety training has been completed and Pediatric CPR and First Aid training is complete and expires on 9/18/2023. Licensee’s Mandated Reporter training is complete and expires 7/21/2024. LPA obtained the fire/disaster drill log, log is complete with the last drill logged 2/02/2023. All adults living and working in the home have obtained a criminal record clearance. All required forms are posted in the room attached to the backyard. LPA obtained a sample of children’s files, helpers file, and facility roster. All files were complete.

Licensee was reminded that California Law requires Licensee to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. The Licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing. Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov.
Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting http://www.mandatedreporterca.com

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: SRIVASTAVA, SHALINI	FACILITY NUMBER: 073407162
	VISIT DATE: 04/12/2023

NARRATIVE

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LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Licensee Shalini Srivastava.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC809 (FAS) - (06/04)

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